The Mockett's Wood Surgery Also known as The Partners T/A Mocketts Wood Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Medicine management required improvement. Some patients had not been appropriately monitored or advised of potential risks relating to their prescribed medicines. The provider had not ensured appropriate antibiotic stewardship was followed by clinicians. There were not effective triage systems in place to ensure patients were consistently assessed by the most appropriate clinician. Some clinicians were not effectively overseen to ensure safe and effective practice. The provider had not ensured staff received regular appraisals to ensure patients received safe care and treatment.

The service encouraged staff to report concerns. Managers investigated incidents thoroughly. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. Managers made sure staff received training.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew how to raise concerns and told us they were supported to do so. They believed leaders and colleagues were committed to investigating, resolving and learning from incidents. Where improvements were required, information, advice and guidance were shared verbally among staff to improve the safety and standards of care.

There were established systems in place to capture concerns from patients, staff, and partner services. Incidents and complaints were investigated in a timely and appropriate manner. Honest and transparent accounts were provided to people and where appropriate, lessons learnt and shared to improve the service.

Staff were able to provide us with examples of learning identified from incidents. For example, the provider had identified and arranged additional emergency response training to improve staff confidence and response in future events.

There were not effective processes in place to ensure people were consistently notified of some potential risks to their health and well being. For example, we found some patients with a high blood sugar levels had not been notified of their results of tests and/or follow up arrangements made with them to assess and support them to manage their health.

Staff monitored some people’s progress along care pathways to identify barriers to accessing and maintaining care, escalated risks to partnership forums for resolution where appropriate. We found there were systems in place to support people as they moved between services.

The views of people who used their services, partners and staff were listened to and taken into account. Policies and processes about safety were aligned with other key partners who were involved in people’s care journey to enable shared learning and drive improvement.

Clinical meetings were held. Staff were familiar with individual needs and we found there was a collaborative, joined-up approach to people’s care.

Patients were encouraged and supported to engage with staff and other partners in their care. Staff were aware of patient care journeys and told us how they liaised with partners to assist them.

The provider actively monitored referrals, admissions and discharges from services.

There were systems in place for processing information relating to new patients.

Clinical records did not consistently show engagement and oversight by the safeguarding lead endorsing actions taken by the staff. For example, the safeguarding lead had not approved a staff member to conduct a home visit where some of the staff believed there may have been safeguarding concerns.

Staff told us and provided illustrative examples of engaging and contributing to collaborative working.

Staff were trained in safeguarding. They understood, applied and adhered to Gillick competency (often used to assess whether a child is mature enough to consent to treatment), Fraser guidelines (used specifically for children requesting contraceptive or sexual health advice and treatment) and the Mental Capacity Act. Staff told us they worked regularly and collaboratively with partner health and social care services to coordinate support and meet individual’s needs.

The practice had established and effective systems in place to safeguard vulnerable adults and children. Records of vulnerable people were regularly revised to ensure information was current and relevant. We saw children had been appropriately followed up with when they failed to attend appointments with primary and or secondary care services.

People told us they were involved in decisions relating to their care. Staff were supportive when communicating their needs, emotions or distress. They were supported to identify and respond to changes in their health.

Staff told us they worked with people to understand and manage risks. They tried to coordinate care and support people to do things that matter to them. People were signposted to support services and respected their choices they make relating to their personal care.

There were not established and effective processes in place to support the early recognition and timely response to risks. People had not been notified of the results of tests in a timely manage to enable them to manage their health.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff told us they had undertaken training in health and safety and practice procedures. Staff had been trained in emergency first aid. Staff could alert colleagues to concerns such as verbal or physical abuse via their clinical system whilst providing care or support to patients and this was regularly tested.

We found staff assisted people with doors on entry into the practice in the absence of assisted entry doors. People had access to chairs with arms in the waiting areas to assist those with limited mobility. There were appropriate child changing facilities with appropriate restraint belt to mitigate the risk of the child falling whilst being changed. Clinical staff used single use items and had access to body fluid spillage kits to mitigate the risk of infection to patients. We saw fire safety wardens were on duty and all staff were aware of evacuation procedures and had rehearsed them. Information was displayed throughout the practice and on their website promoting dignity and respect to people and the standards of conduct expected.

There were established and effective systems in place to identify, manage and mitigate risks to people. For example; the practice had conducted environmental risk assessments (including legionella testing and portable appliance testing) to ensure staff and people were safe and revised them annually or more frequently in response to changes. We saw the practice had followed up on fire risks such as the relocation of bins and self-closing on fire doors.

Maintenance contracts were in placed to maintain the accuracy of equipment (calibration), scheduled safety checks were conducted on the fire alarm system, emergency lighting and equipment. Staff had undergone Disclosure and Barring Service checks (DBS is a way for employers to assess the suitability of individuals for certain roles) or if a DBS had not been completed, appropriate risk assessments were in place.

The practice had not ensured all staff received effective support, supervision and development. We found learning needs and development of some staff were not always identified. Some clinical staff had not been regularly assessed to ensure they were safe to carry out their role and operating in their agreed scope of competencies. For example, we found a member of the clinical team had not had recorded supervisions or assessments of their clinical practise since their appointment in 2023. On review of clinical records, we identified that this member of staff had not always acted in line with their agreed areas of competence. They had not sought support from the supervising clinician to ensure patient outcomes were appropriate and prescribing decisions were not always supported by national guidelines or recorded appropriately.

Staff and leaders understood the recruitment and disciplinary processes and believed they were fair. The management team ensured they were applied appropriately to ensure there was no disadvantage based on any specific protected equality characteristic. Staff told us appropriate staffing levels and skill mix was maintained. Staff had professional development opportunities.

We found safe recruitment practices were employed when appointing clinical and non-clinical staff, including locum staff. Staff were required to complete mandatory training and had opportunities to complete further training relevant to their role. Clinical staff maintained their professional revalidation.

Following assessment, the provider confirmed that they had reviewed their clinical model and would no longer recruit non-medical prescribers. They also confirmed that they had implemented a supervision policy. However, we were unable to assess the impact of these changes.

We found the practice to be clean, tidy and well maintained. The practice had a designated infection, prevention and control lead. Cleaning schedules were in place for rooms and equipment and had been appropriately completed. Additional checks were conducted by the management team to ensure standards for cleanliness were maintained. We checked cleaning cupboards and found all cleaning items had appropriate processes in place to control substances hazardous to people’s health.

The practice assessed and managed the risk of infection. Risk assessments and audits were completed, and actions taken to mitigate risks. Staff told us they had been appropriately vaccinated to mitigate the risk to them and others, of infection. They received training in infection prevention control and additional refresher information. They had access to barrier controls and gloves, apron’s and masks to mitigate the risk of infection to people. Staff explained to us how they triaged and managed patients with potentially contagious diseases. There were established and effective systems in place for identifying, assessing and managing the risk of infection, which is in line with current relevant national guidance. They shared concerns with appropriate agencies promptly.

There were not established and effective systems in place to ensure the safe and effective management of some medicines.

We found there was no established and effective system in place to ensure appropriate Medicines and Healthcare products Regulatory Agency (MHRA) alerts (providing alerts, recalls and safety information on drugs and medical devices) were consistently reviewed and actioned. For example, we identified 76 patients prescribed the medicine detailed in the alert. Out of our sample of five patients we found all potentially at risk of harm. We found some people had not been appraised of the potential risks of skin cancer associated with the prescribed medicine. This was brought to the attention of the provider who immediately reviewed the care provided.

We found inconsistencies in the quality of medicine reviews conducted by some clinicians. For example, we reviewed a sample of clinical records and identified medicine reviews which did not contain necessary information to support the continued prescribing of medicines. For example, we found some clinical records completed by GPs had been coded as having medication reviews completed but did not include a narrative entry on the record to demonstrate what had been considered and how they had been assured thee medicines were safe to continue to prescribe.

Following inspection, the practice reviewed their patients care. They told us they intended to use clinical templates in the future to improve the quality of the clinical assessment and promote safe and well documented decisions.

We found the practice had not ensured antibiotics were prescribed in line with national guidance. The practice was identified as a local outlier/high prescriber for antibiotics by the local Integrated Care Board. The practice had audited their prescribing behaviours and identified significant improvement were required in the information provided to patients and their assessment of peoples need. However, they had not established systems to address individual prescribing behaviours to ensure they adhered to national guidance or local priorities. (Antibiotic stewardship is crucial for preserving the effectiveness of antibiotics and combating antimicrobial resistance).

Following assessment, the provider sent us an action plan demonstrating how they intended to reduce antibiotic prescribing. However, we were unable to assess the impact and effectiveness of this action plan.

We found some suggested emergency medicines were not available to staff should they have to respond to an emergency. There was no risk assessment in place to identify an alternative medicine. For example; the practice did not have midazolam or diazepam to treat people who have a seizure.

Medicines were stored appropriately in accordance with cold chain procedures to maintain their integrity. We found up-to-date information about people’s medicines was available, particularly when they moved between health and care settings.